Profiling Ultrafiltration Goals of UF Profiling • • • • Provide adequate ultrafiltration (UF) Minimize symptoms related to hypovolemia Enhance plasma refill Allow the patient to reach estimated dry weight.
Download ReportTranscript Profiling Ultrafiltration Goals of UF Profiling • • • • Provide adequate ultrafiltration (UF) Minimize symptoms related to hypovolemia Enhance plasma refill Allow the patient to reach estimated dry weight.
Slide 1
Profiling
Ultrafiltration
1
Slide 2
Goals of UF Profiling
•
•
•
•
2
Provide adequate ultrafiltration (UF)
Minimize symptoms related to hypovolemia
Enhance plasma refill
Allow the patient to reach estimated dry
weight (EDW)
Hypovolemia: Decreased blood volume leads
Plasma refill: Refilling
of the blood
compartment, or
vascular space from
the surrounding tissue
spaces.
to decreased cardiac output which can cause
hypotension.
Slide 3
Fluid Spaces in the Body
Average weight Male
70 kg or 154 lbs.
3
VASCULAR SPACE
4 LITERS WATER, 5%
INTERSTITIAL SPACE
11 LITERS WATER, 15%
INTRACELLULAR
SPACE
27 LITERS
WATER
40%
Extracellular
60% of Total
Body Weight
is
42 liters
of
water
BONE, MUSCLE, FAT
Slide 4
Two basic reasons that Patients end up
with dialysis symptoms during treatment
•
•
The loss of circulating volume in the vascular
space
The loss of osmolarity as the urea is removed
during dialysis (see section - Conductivity
Profiling)
Only fluid in the vascular space is available
during dialysis for ultrafiltration. This
amounts to less than 4L in the average
patient.
4
Slide 5
Symptom Etiology
with Constant Ultrafiltration
Ultrafiltration
(UF) removes
water volume
from the blood
into the
dialysate,
causing
hypovolemia
Symptoms
of Volume
loss:
•Hypotension
•Cramping
•Dizziness
•Nausea
•Vomiting
•Shock
5
Slide 6
Profiling Ultrafiltration:
• Allows the patient to reach their
Estimated Dry Weight (EDW)
• Helps prevent symptoms
• Allows refilling of vascular fluid volume
from the interstitial space (Plasma
Refill)
• Allows higher volume fluid removal at
times when fluid is more readily
available
• Prevents hypotension
6
Slide 7
How to do UF Profiling
• Identify patients with dialysis related symptoms
• Analyze patient’s treatment records
• Decide if the patient will benefit from a profile
• Choose a profile that matches your analysis
7
Slide 8
Things to consider for
Ultrafiltration Profiling
• Does the patient have difficulty with fluid
removal?
• Have the MD answer these questions:
– What UF rates can the patient tolerate?
– Will the patient require periods of minimum
UF?
– How will patient co-morbidities affect fluid
removal?
– What type of profile would be best suited for
the patient?
8
Slide 9
Individualize the Prescription
based upon the Patient’s
Treatment History
• Determine when the patient typically
demonstrates symptoms. Beginning –
Mid – End of treatment?
• Does the patient need minimum UF to
complete the treatment?
• Evaluate the pre treatment Systolic
Blood Pressure (SBP)
• Evaluate the patient’s weight gains
between treatments
9
Slide 10
Choosing the Right UF Profiles
• A profile that begins with the highest UF that
can be tolerated by the patient which then
decreases to a minimum will work for patients:
•
•
•
•
10
Linear
Progressive
With large weight gains between
treatments
Who become hypotensive late in treatment
Who cramp late or at the end of treatment
With large weight gains between treatments
Step
Step
and present with an elevated BP
Slide 11
Choosing the Right UF Profiles
• Consider a profile with varying steps for
patients who:
• Need a gradual increase in UF at the beginning of
the treatment to support low BP or cardiac output
• Need short intervals of minimum UF to allow for
plasma refill
• Have difficulty shifting fluid into the vascular
space (elderly, diabetic or unstable)
• Cramp or are hypotensive randomly during
treatment
11
Slide 12
Case Studies
How to select a UF profile
for a patient
12
Slide 13
Carl Kramper weight gains
typically of 3-4 kg and
experiences moderate to
severe leg cramps during
the last 30 minutes of
treatment.
13
Slide 14
Patient tolerates fluid
removal (higher UF)
at the beginning of
treatment
220
200
180
Symptoms are
relieved at the
end of treatment
with a lower UF
160
140
120
100
80
UF Profile
60
40
3
0
60
90
120
150 180
Time in Minutes
14
210 240
Slide 15
220
Systolic BP
Fluid overloaded
200
patients benefit from
180
aggressive UF at
1.8
Kg/h
160
the beginning of the
treatment 140
0.7
120
0.3
100
Step profiles allow
for
80
dramatic decreases
in UF.
60
Lower UF at the 40
middle
and90
30 60
end of treatment will reduce
the patient’s symptoms
15
1.0
UF Profile
120
150 180
Time in Minutes
210 240
Slide 16
Harriet Hart arrives with a systolic
blood pressure of 85 and a weight
gain of 3 Kg. If her SBP falls
below 75 she becomes
symptomatic.
16
Slide 17
Less UF
should be used
220
at the beginning of
200while the SBP
treatment
is low. Increase the UF
180
during periods when the
SBP
160is higher
Decrease the UF
toward the end of
treatment as the
patient
approaches her
dry weight to
prevent symptoms
140
120
100
80
60
40
30
60 90
120
150
Time in Minutes
17
180
210
240
Slide 18
220
Using a Step Profile, you can
create multiple minimum UF
periods which will allow
plasma refill to occur.
Decrease the UF toward the
end of treatment as the patient
approaches her dry weight to
prevent symptoms
200
180
160
140
120
100
80
60
40
30
60 90
12
0
150
Time in Minutes
18
180
210
240
Slide 19
Katy Glycemia is hypertensive and
diabetic. She has large fluid gains
of 4-6 Kg between treatments and
has symptoms of hypotension
about 45 minutes into the treatment
as well as mid and late treatment.
19
Slide 20
Assessment and Plan
• Assessment:
– Large fluid gains
– Severe hypotensive episodes
– Poor plasma refill
• Plan
– Support plasma refill, especially during the
first part of the treatment
– Prevent hypovolemia
– Consider conductivity profiling in addition to
UF profiling
20
Slide 21
220
200
Utilize a
Conductivity
profile to support
solute removal
180
160
140
120
100
80
60
40 30
60
90
120 150
Time in Minutes
21
Arrows
indicate
plasma refill
times240
180 210
Slide 22
220
UF and Conductivity Profiling
can be used simultaneously
with similar step curves
200
180
160
140
120
100
80
60
40 30
60
90
120 150 180 210 240
Time in Minutes
22
Slide 23
220
200
Systolic BP
180
160
140
120
UF and Conductivity Profiling
100
can be used simultaneously
with 80
similar progressive curves
60
40 30
60
90
120 150 180 210 240
Time in Minutes
23
Slide 24
Summary of UF Profiling
• Allows unlimited variation of ultrafiltration
rates so that fluid can be removed from the
vascular space while preventing symptoms
• Allows periods of automatic plasma refilling
to allow adequate fluid removal
• Decreases the patient’s symptoms
• May be used simultaneously with
Conductivity Profiling
24
Slide 25
References
Heinrich, W.L. & Victor, R.G., “Autonomic Neuropathy and
Hemodynamic Stability in End-Stage Renal Disease Patients”,
Principles and Practice in Dialysis, Williams and Wilkins,
Baltimore, 1994.
Wilson, S., Alvarez, D., A Primer on Ultrafiltrtion Profiling and
Sodium Modeling for Dialysis Patients, Contemporary Dialysis
and Nephrology, April 2000, pp 34-36.
Bonomini, V., Coli, L., Scolari, M.P., Profiling Dialysis: A New
Approach to Dialysis Intolerance, Nephron 1997; 75:1-6
Leunissen, K.M.L., Kooman, J.P., van der Sande, F.M., van Kuijk,
W.H.M., Hypotension and Ultrafiltration Physiology in Dialysis,
Blood Purif 2000; 18:251-254
Oliver, M.J., Edwards, L.J., Churchill, Impact of Sodium and
Ultrafiltration Profiling on Hemodialysis Related Symptoms, J
Am Soc Nephrol 12: 151-156 2000
Jensen, B.M., Dobbe, S. A., Squillace, D.P., McCarthy, J.T., (April
1994) Clinical Benefits of High and Variable Sodium Concentration
Dialysate in Hemodialysis Patients, ANNA Journal, Vol. 21, No. 2.
25
Slide 26
References
Gambro Basics 1 Gambro Education 1994
Petitclerc, T. and Jacobs, C. Dialysis sodium concentration: what is optimal
and can it be individualized? , Nephrol Dial Transplant Editorial
Comments1995, 596-599.
Coli, L., Ursino, M., Dalmastri, V., Volpe, F., LaManna, G., Avanzolini, G.,
Stefoni, S., Bonomini, V., A simple mathematical model applied to selection of
the sodium profile during profiled haemdialysis, Nephrol Dial Transplant
(1998) 13:404-416
Donauer,J., Kolblin, D., Bek, M., Krause, A., Bohler, J., Ultrafiltration Profiling
and Measurement of Reletive Blood Volume as Strategies to Reduce
Hemodialysis-Related Side Effects, AJKD, Vol 36, No 1 (July), 2000:pp115123
Stiller, S., Bonnie-Schorn, E., Grassmann, A., Uhlenbusch-Korwer, Mann, A
Critical Review of Sodium Profiling for Hemodialysis, Seminars in Dialysis, Vol
14, No 5 (September-October) 2001 pp. 337-347
Locatelli, F., DiFilippo, S., Manzoni, C., Corti, M., Andrulli, S., Pontoriero, G.,
Monitoring sodium removal and delivered dialysis by conductivity, The
International Journal of Artificial Organs/Vol. 18/no. 11, 1995/pp716-721
26
Profiling
Ultrafiltration
1
Slide 2
Goals of UF Profiling
•
•
•
•
2
Provide adequate ultrafiltration (UF)
Minimize symptoms related to hypovolemia
Enhance plasma refill
Allow the patient to reach estimated dry
weight (EDW)
Hypovolemia: Decreased blood volume leads
Plasma refill: Refilling
of the blood
compartment, or
vascular space from
the surrounding tissue
spaces.
to decreased cardiac output which can cause
hypotension.
Slide 3
Fluid Spaces in the Body
Average weight Male
70 kg or 154 lbs.
3
VASCULAR SPACE
4 LITERS WATER, 5%
INTERSTITIAL SPACE
11 LITERS WATER, 15%
INTRACELLULAR
SPACE
27 LITERS
WATER
40%
Extracellular
60% of Total
Body Weight
is
42 liters
of
water
BONE, MUSCLE, FAT
Slide 4
Two basic reasons that Patients end up
with dialysis symptoms during treatment
•
•
The loss of circulating volume in the vascular
space
The loss of osmolarity as the urea is removed
during dialysis (see section - Conductivity
Profiling)
Only fluid in the vascular space is available
during dialysis for ultrafiltration. This
amounts to less than 4L in the average
patient.
4
Slide 5
Symptom Etiology
with Constant Ultrafiltration
Ultrafiltration
(UF) removes
water volume
from the blood
into the
dialysate,
causing
hypovolemia
Symptoms
of Volume
loss:
•Hypotension
•Cramping
•Dizziness
•Nausea
•Vomiting
•Shock
5
Slide 6
Profiling Ultrafiltration:
• Allows the patient to reach their
Estimated Dry Weight (EDW)
• Helps prevent symptoms
• Allows refilling of vascular fluid volume
from the interstitial space (Plasma
Refill)
• Allows higher volume fluid removal at
times when fluid is more readily
available
• Prevents hypotension
6
Slide 7
How to do UF Profiling
• Identify patients with dialysis related symptoms
• Analyze patient’s treatment records
• Decide if the patient will benefit from a profile
• Choose a profile that matches your analysis
7
Slide 8
Things to consider for
Ultrafiltration Profiling
• Does the patient have difficulty with fluid
removal?
• Have the MD answer these questions:
– What UF rates can the patient tolerate?
– Will the patient require periods of minimum
UF?
– How will patient co-morbidities affect fluid
removal?
– What type of profile would be best suited for
the patient?
8
Slide 9
Individualize the Prescription
based upon the Patient’s
Treatment History
• Determine when the patient typically
demonstrates symptoms. Beginning –
Mid – End of treatment?
• Does the patient need minimum UF to
complete the treatment?
• Evaluate the pre treatment Systolic
Blood Pressure (SBP)
• Evaluate the patient’s weight gains
between treatments
9
Slide 10
Choosing the Right UF Profiles
• A profile that begins with the highest UF that
can be tolerated by the patient which then
decreases to a minimum will work for patients:
•
•
•
•
10
Linear
Progressive
With large weight gains between
treatments
Who become hypotensive late in treatment
Who cramp late or at the end of treatment
With large weight gains between treatments
Step
Step
and present with an elevated BP
Slide 11
Choosing the Right UF Profiles
• Consider a profile with varying steps for
patients who:
• Need a gradual increase in UF at the beginning of
the treatment to support low BP or cardiac output
• Need short intervals of minimum UF to allow for
plasma refill
• Have difficulty shifting fluid into the vascular
space (elderly, diabetic or unstable)
• Cramp or are hypotensive randomly during
treatment
11
Slide 12
Case Studies
How to select a UF profile
for a patient
12
Slide 13
Carl Kramper weight gains
typically of 3-4 kg and
experiences moderate to
severe leg cramps during
the last 30 minutes of
treatment.
13
Slide 14
Patient tolerates fluid
removal (higher UF)
at the beginning of
treatment
220
200
180
Symptoms are
relieved at the
end of treatment
with a lower UF
160
140
120
100
80
UF Profile
60
40
3
0
60
90
120
150 180
Time in Minutes
14
210 240
Slide 15
220
Systolic BP
Fluid overloaded
200
patients benefit from
180
aggressive UF at
1.8
Kg/h
160
the beginning of the
treatment 140
0.7
120
0.3
100
Step profiles allow
for
80
dramatic decreases
in UF.
60
Lower UF at the 40
middle
and90
30 60
end of treatment will reduce
the patient’s symptoms
15
1.0
UF Profile
120
150 180
Time in Minutes
210 240
Slide 16
Harriet Hart arrives with a systolic
blood pressure of 85 and a weight
gain of 3 Kg. If her SBP falls
below 75 she becomes
symptomatic.
16
Slide 17
Less UF
should be used
220
at the beginning of
200while the SBP
treatment
is low. Increase the UF
180
during periods when the
SBP
160is higher
Decrease the UF
toward the end of
treatment as the
patient
approaches her
dry weight to
prevent symptoms
140
120
100
80
60
40
30
60 90
120
150
Time in Minutes
17
180
210
240
Slide 18
220
Using a Step Profile, you can
create multiple minimum UF
periods which will allow
plasma refill to occur.
Decrease the UF toward the
end of treatment as the patient
approaches her dry weight to
prevent symptoms
200
180
160
140
120
100
80
60
40
30
60 90
12
0
150
Time in Minutes
18
180
210
240
Slide 19
Katy Glycemia is hypertensive and
diabetic. She has large fluid gains
of 4-6 Kg between treatments and
has symptoms of hypotension
about 45 minutes into the treatment
as well as mid and late treatment.
19
Slide 20
Assessment and Plan
• Assessment:
– Large fluid gains
– Severe hypotensive episodes
– Poor plasma refill
• Plan
– Support plasma refill, especially during the
first part of the treatment
– Prevent hypovolemia
– Consider conductivity profiling in addition to
UF profiling
20
Slide 21
220
200
Utilize a
Conductivity
profile to support
solute removal
180
160
140
120
100
80
60
40 30
60
90
120 150
Time in Minutes
21
Arrows
indicate
plasma refill
times240
180 210
Slide 22
220
UF and Conductivity Profiling
can be used simultaneously
with similar step curves
200
180
160
140
120
100
80
60
40 30
60
90
120 150 180 210 240
Time in Minutes
22
Slide 23
220
200
Systolic BP
180
160
140
120
UF and Conductivity Profiling
100
can be used simultaneously
with 80
similar progressive curves
60
40 30
60
90
120 150 180 210 240
Time in Minutes
23
Slide 24
Summary of UF Profiling
• Allows unlimited variation of ultrafiltration
rates so that fluid can be removed from the
vascular space while preventing symptoms
• Allows periods of automatic plasma refilling
to allow adequate fluid removal
• Decreases the patient’s symptoms
• May be used simultaneously with
Conductivity Profiling
24
Slide 25
References
Heinrich, W.L. & Victor, R.G., “Autonomic Neuropathy and
Hemodynamic Stability in End-Stage Renal Disease Patients”,
Principles and Practice in Dialysis, Williams and Wilkins,
Baltimore, 1994.
Wilson, S., Alvarez, D., A Primer on Ultrafiltrtion Profiling and
Sodium Modeling for Dialysis Patients, Contemporary Dialysis
and Nephrology, April 2000, pp 34-36.
Bonomini, V., Coli, L., Scolari, M.P., Profiling Dialysis: A New
Approach to Dialysis Intolerance, Nephron 1997; 75:1-6
Leunissen, K.M.L., Kooman, J.P., van der Sande, F.M., van Kuijk,
W.H.M., Hypotension and Ultrafiltration Physiology in Dialysis,
Blood Purif 2000; 18:251-254
Oliver, M.J., Edwards, L.J., Churchill, Impact of Sodium and
Ultrafiltration Profiling on Hemodialysis Related Symptoms, J
Am Soc Nephrol 12: 151-156 2000
Jensen, B.M., Dobbe, S. A., Squillace, D.P., McCarthy, J.T., (April
1994) Clinical Benefits of High and Variable Sodium Concentration
Dialysate in Hemodialysis Patients, ANNA Journal, Vol. 21, No. 2.
25
Slide 26
References
Gambro Basics 1 Gambro Education 1994
Petitclerc, T. and Jacobs, C. Dialysis sodium concentration: what is optimal
and can it be individualized? , Nephrol Dial Transplant Editorial
Comments1995, 596-599.
Coli, L., Ursino, M., Dalmastri, V., Volpe, F., LaManna, G., Avanzolini, G.,
Stefoni, S., Bonomini, V., A simple mathematical model applied to selection of
the sodium profile during profiled haemdialysis, Nephrol Dial Transplant
(1998) 13:404-416
Donauer,J., Kolblin, D., Bek, M., Krause, A., Bohler, J., Ultrafiltration Profiling
and Measurement of Reletive Blood Volume as Strategies to Reduce
Hemodialysis-Related Side Effects, AJKD, Vol 36, No 1 (July), 2000:pp115123
Stiller, S., Bonnie-Schorn, E., Grassmann, A., Uhlenbusch-Korwer, Mann, A
Critical Review of Sodium Profiling for Hemodialysis, Seminars in Dialysis, Vol
14, No 5 (September-October) 2001 pp. 337-347
Locatelli, F., DiFilippo, S., Manzoni, C., Corti, M., Andrulli, S., Pontoriero, G.,
Monitoring sodium removal and delivered dialysis by conductivity, The
International Journal of Artificial Organs/Vol. 18/no. 11, 1995/pp716-721
26